Skip to main content

New procedure for submitting letters

  • Patricia Casey and Jonathan Pimm
  • View HTML
    • Send article to Kindle

      To send this article to your Kindle, first ensure is added to your Approved Personal Document E-mail List under your Personal Document Settings on the Manage Your Content and Devices page of your Amazon account. Then enter the ‘name’ part of your Kindle email address below. Find out more about sending to your Kindle. Find out more about sending to your Kindle.

      Note you can select to send to either the or variations. ‘’ emails are free but can only be sent to your device when it is connected to wi-fi. ‘’ emails can be delivered even when you are not connected to wi-fi, but note that service fees apply.

      Find out more about the Kindle Personal Document Service.

      New procedure for submitting letters
      Available formats
      Send article to Dropbox

      To send this article to your Dropbox account, please select one or more formats and confirm that you agree to abide by our usage policies. If this is the first time you use this feature, you will be asked to authorise Cambridge Core to connect with your <service> account. Find out more about sending content to Dropbox.

      New procedure for submitting letters
      Available formats
      Send article to Google Drive

      To send this article to your Google Drive account, please select one or more formats and confirm that you agree to abide by our usage policies. If this is the first time you use this feature, you will be asked to authorise Cambridge Core to connect with your <service> account. Find out more about sending content to Google Drive.

      New procedure for submitting letters
      Available formats
This is an Open Access article, distributed under the terms of the Creative Commons Attribution (CC-BY) license (, which permits unrestricted re-use, distribution, and reproduction in any medium, provided the original work is properly cited.
Recommend this journal

Email your librarian or administrator to recommend adding this journal to your organisation's collection.

BJPsych Bulletin
  • ISSN: 0955-6036
  • EISSN: 1472-1473
  • URL: /core/journals/bjpsych-bulletin
Please enter your name
Please enter a valid email address
Who would you like to send this to? *


Full text views

Total number of HTML views: 4
Total number of PDF views: 14 *
Loading metrics...

Abstract views

Total abstract views: 710 *
Loading metrics...

* Views captured on Cambridge Core between 2nd January 2018 - 21st June 2018. This data will be updated every 24 hours.

New procedure for submitting letters

  • Patricia Casey and Jonathan Pimm
Submit a response


Maintenance doses for Clozapine: past and present

AVNEET SHARMA, Consultant Psychiatrist, Avon and Wiltshire Mental Health Partnership NHS Trust
19 June 2018

We recently completed a QIP for patients on long term Clozapine with the main aim of assessing the side effect burden with a view to optimise the treatment. We compare our current clinical practice with one described in a publication 20 years ago in Psych bulletin 1998(1) (Murphy et al) on maintenance doses for Clozapine.

Murphy et al⁽¹⁾ presented findings on forty four patients who have been on Clozapine for 6 months or more . Our patient number was Forty one and the information was retrieved from electronic case records though this did not make the job easier as the relevant information was scattered around across time in different sections of the record system.

The patient group in Murphy’s study had a mean age of 38 years (21 to 62 years) with 35 males and nine females, majority being Caucasian with mean duration of Clozapine treatment of 38 months (7-69months). The highest treatment dose prescribed ranged from 300 mg to 900 mg per day (mean 568 mg) with 50% patients on 500 mg per day or less, only one patient received the maximum dose of 900 mg. The current or maintenance doses of Clozapine ranged from 150 mg to 750 mg per day (mean460 mg) with eight patients on doses of 150 and 300 mg per day which was within the then BNF guidelines. British National Formulary (BNF: number 33, March 1997) guidelines at the time clearly differentiated between the higher doses (200-450 mg daily, maximum 900 mg) required initially to stabilise the mental state, and the lower doses (150mg-300 mg daily) required subsequently for maintenance treatment. The authors found that dosage reductions had been achieved in 29 cases while no attempt to reduce the dose in majority of the rest of the patients was due to partial response or less than expected symptom control.

Our group had older patients with a mean age of 44 years (29-70 years) and were predominantly Caucasian y with 30 males and 11 females and mean duration of treatment with Clozapine was more than 10 years (range of 1-30 years). The dose ranged from 200 -900mg per day with mean dose of 405 mg per day; 25 patients were on doses between 300mg -500 mg per day which would have been deemed higher as per BNF guidelines of 1997.

We found that that 80% of patients were reporting significant side effects including drooling, sedation/tiredness, GI Symptoms, weight gain, urinary incontinence, constipation. Also a significant proportion (50%) were on side effects medications generally in combination There were significant metabolic problems with average BMI of 29.40 with most of the patients apart from 5 having BMI above 23; two cases were diagnosed with diabetes and on treatment.

We also found that there has been no reduction in Clozapine doses in any of the cases over at least last 7 years at least including more recent cases. Of course one big difference is that there are no current British National Formulary guidelines for the maintenance doses for Clozapine, BNF(September 2016- March 2017) mentions usual dose range for Clozapine of 200 mg to 450 mg per day that one needs to titrate to while starting clozapine.

The side effect burden on its own should be enough to make clinicians keep dose review on agenda on regular basis. Due to large variations in metabolism it is hard to predict the optimum dose and plasma level in individual patient, the manufactures ⁽²⁾ advise that once maximum therapeutic benefit has been established, many patients can be maintained effectively on lower doses with careful downward titration. The past BNF guidelines regarding maintenance doses were thought to be not based on evidence (1) but empirical; may be it is time to revisit the past as patients appeared to be getting a better deal.


1. Bernadette Murphy, Colm Long and Carol Patton- Maintenance doses for clozapine Psychiatry Bulletin

(1998)22, 12-14.

2. Beelen, Van AJ; Jollie-Helthuis M (2013) Zaponex Fact Sheet Clozapine dosing and metabolism

Doc.05.SOP.LNL.600.01 Mar 2013
... More

Conflict of interest: None declared

Write a reply

How does current guidance affect the use of long term segregation by forensic psychiatrists in the United Kingdom?

Gareth Garrett, ST5 Forensic Psychiatry, Nottinghamshire Healthcare NHS Foundation Trust
Nicholas Taylor, Consultant Forensic Psychiatrist, Nottinghamshire Healthcare NHS Foundation Trust
18 June 2018

The Mental Health Act Code of Practice 2015 expanded the guidance on restrictive practices such as seclusion and long-term segregation. Recommendations were made regarding the physical conditions within which patients could be segregated, the reporting requirements, and how local policy and procedure should shape practice.1

Guidance around restrictive practice is welcomed, as part of the agenda to reduce these interventions,2,3 however it is accepted that there remain occasions when such measures are necessary.4

It is our experience that long term segregation in particular is used differently by teams even within the same service.

We were curious how familiar clinicians were to the guidance in the 2015 code, how restrictive practices were used in different areas and any relevant impact on clinical practice.

A questionnaire was devised to capture the experience of Consultant Forensic Psychiatrists. It was made available. Links were sent to representatives for forensic psychiatry training schemes in the United Kingdom for wider circulation to colleagues. Data was collected over a period of one month.

There were 25 respondents in total.

There was an equal spread of respondents when asked about their knowledge of the changes to the guidance on long-term segregation. On a five-point Likert scale, 44% identified themselves as confident, with the same number describing themselves as unconfident. One respondent commented that it was necessary to refer back to the Code as long-term segregation was not used often.

Respondents commented that long-term segregation was not clearly defined, and that the guidance around the frequency of review was poor. The requirements around independent reviews were regarded as unclear.

A large majority of respondents said that seclusion was easier to use in their place of work. Over two thirds of respondents said that long-term segregation required more paperwork.

Many barriers for the use of long-term segregation were described. These included the physical security measures required for its safe and appropriate use, and the amount of paperwork required. Despite this, 60% of respondents felt that long-term segregation was valuable to clinical practice.

Long-term segregation remains a useful tool for patients with a history of institutional violence who have spent long periods of time in seclusion. For some patients, long–term segregation may represent the least restrictive environment within which they can be safely managed. Clinicians may be discouraged from using such an intervention due to the nature of ward environments or the necessary reporting requirements.

The results of the survey confirmed anecdotal reports that patients may well be detained in more restrictive conditions (seclusion rather than LTS) because the bureaucratic process around seclusion is easier to navigate. This is a matter of concern and we would urge a review of the Code of Practice and of procedures within mental health providers to ensure that this imbalance is corrected as a priority.


1. Department of Health. Mental Health Act 1983: Code of Practice. TSO (The Stationary Office), 2015.

2. Tully J, McSweeney L, Harfield K, Castle C, Das M. Innovation and pragmatism required to reduce seclusion practices. CNS Spectrums 2016; 21(6) 424-429

3. Gaskin C, Elsom S, Happell B. Interventions for reducing the use of seclusion in psychiatric facilities: review of the literature. British Journal of Psychiatry 2007; 191 298-303

4. National Institute for Health and Care Excellence. Violence and aggression: short-term management in mental health, health and community settings. (NICE Guideline 10) Available at: [Accessed 06 February 2018]

... More

Conflict of interest: None declared

Write a reply

Clinical Audit on Cardiac Monitoring in Patients on Acetylcholinesterase Inhibitors under the care of Psychogeriatrics Team in Hong Kong

Mei Cheung Wong, Psychiatrist, United Christian Hospital
Edwin Pui-fai Pang, Psychiatrist, United Christian Hospital
23 May 2018

Acetylcholinesterase inhibitors (AChEI) are commonly prescribed for Alzheimer's, mixed, Parkinson's and Lewy Body Dementia in elderly patients. Studies have shown that AChEI's can slow heart rate in those with an existing cardiac abnormality and increase the risk of falls¹. No national guideline is available concerning pre-treatment investigations that are needed before commencing AChEIs. Many clinicians obtain a routine electrocardiogram (ECG) before starting treatment. Access to ECG varies. Support available to clinicians to interpret ECG findings also varies. Over-reliance on automated reports without additional skills in ECG interpretation may lead to unnecessary changes in AchEI prescribing with patients unnecessarily being denied access to treatment².

In 2016, the ECG Reference Group (ERG) of Yorkshire & Humber Clinical Networks had developed a guideline³ to support consistent, evidence-based practice in the cardiac pre-assessment and monitoring of AChEIs. It found that there was no compelling evidence that undertaking a routine ECG in all patients prior to initiating AChEIs was either justifiable or effective. It recommends that service providers should consider adopting the pathway proposed by Rowland et al⁴. Pulse checking should be done shortly before AChEIs are to be initiated and repeated after one month. Baseline ECG is to be done in high risk groups (unexplained syncope, bradycardia, and patients taking other cardiac rate-limiting drugs). If the dose of the AChEI is to be titrated up, the pulse rate and symptoms should be reassessed after a further month. If the pulse rate is above 60 bpm and the patient is asymptomatic, they can be rechecked at 6 months and then annually.

We have done a clinical audit to assess the cardiac monitoring according to the recommendation. 250 patients under the care of the Psychogeriatrics team (PGT) in our hospital were taking AChEIs. Sixty three of them (25%) who had followed up in a specified month were chosen for the audit. Among these patients taking AChEIs, 47 of them were started by PGT doctors while the others were started by other doctors before the patients were referred to us. There was no pulse check at baseline for five patients when AChEIs were started by us (10.6%). There was no ongoing pulse monitoring performed for any patients. ECG was performed for 39 patients (83%) of those with AChEIs started by us. Seven patients were also taking concomitant rate-limiting drugs. AChEIs were started by PGT doctors in five of these patients and baseline ECG was done in four of them (80%); baseline pulse rate was checked in all of these patients. However, no ongoing pulse monitoring was done for these patients.

In order to improve adherence to the recommendations PGT doctors were informed about the audit results and guidelines in the form of a lecture. It was further discussed in team meetings. A guideline on cardiac monitoring for patients on AChEIs was developed. A re-audit was done after six months and 70 patients were involved. 48 (68.6%) of them had pulse check during follow up. Two patients were recently started on AChEI and baseline pulse rate was checked and repeated after about one month. Another two patients were noted to have a pulse rate lower than 60 bpm. ECG was ordered for 1 patient. AChEI was planned to tail off for another patient according to the case notes.

Baseline audit results showed that PGT doctors would do a baseline pulse check before initiation of AChEI most of the time. As ECG is readily available in our hospital they would even order ECG for these patients. This is good practice if resources are available and there are adequate skills in interpreting ECG results. There is a need to bear in mind that evidence from previous studies showed that psychiatrists may read ECGs inaccurately⁵.

Ongoing pulse monitoring was not performed by all doctors. In the re-audit improvement in the level of adherence suggested that the use of an educational session, discussion in meetings, and development of guidelines were useful in changing monitoring practice.


1. Park-Wyllie LY et al. Cholinesterase inhibitors and hospitalization for bradycardia: a population-based study. PLoS Med 2009;6:e1000157.

2. Estes NM. Computerized Interpretation of ECGs: Supplement Not a Substitute. Circ Arrhythm Electrophysiol 2013;6:2-4

3. Yorkshire & Humber Clinical Networks. The Assessment of Cardiac Status Before Prescribing Acetylcholinesterase Inhibitors for Dementia. 2016. Available from:

4. Rowland JR. Cardiovascular monitoring with acetylcholinesterase inhibitors: A clinical protocol.Advances in Psychiatric Treatment2007;13:178-184.

5. Collins N. et al. Junior psychiatrists’ electrocardiogram interpretation skill. BJPsychBulletin 2008;32(9):353-355.
... More

Conflict of interest: None declared

Write a reply

Commensality and food as a way to combat loneliness and isolation in the elderly

Victor Aziz
Rugiyya Saeed
Alex Bradwell
27 April 2018

Food and drink, aside from their fundamental role in nutrition and meeting our physiological needs, also provide a sense of belonging to ethnic, religious or even geographic groups¹’² Each community has their own food culture, and it is acknowledged that traditional food and customs contribute to social cohesion³.

The act of eating with others, known as commensality, leads to the building of kinship, and over the years sharing mealtimes have been integral in maintaining the family as a social unit. In some cultures, meals can also serve as a platform for narratives that share moral messages, a way to learn, influence and transform each other’s thoughts and actions⁴.

The social ties built via commensality leads to a higher quality of life and overall well-being⁵’⁶. Those without strong social relationships are at an increased risk of deviant behaviour, such as suicide. One theory is the lack of social constraints leads to such behaviours⁷. A second hypothesis suggests having a stable social network protects individuals from negative outcomes by providing them with a meaningful existence⁷.

Whilst food and mealtimes are important for strengthening one’s social network, the level of social interaction has an equally significant impact on the enjoyment of mealtimes. Eating with friends and family can increase food intake⁸ and encourage individuals to engage in socially sanctioned eating behaviours such as having regular healthier meals⁹.

With increasingly busy lives and a growing number of people living on their own, eating together is often overlooked¹⁰⁻¹², especially for the younger population who are very reliant on social interaction via social networking services. However there still appears to be a demand to meet with friends and families in restaurants, parties, and other social settings.

Older people may not be able to participate in these aspects of social interaction due to, although not limited to, frailty, cognitive impairment, geography and wariness of technology. Consequently, isolation and lack of meaningful social relationships make loneliness common in older people with studies suggesting 5% to 16% of the older population report feeling lonely¹³. Approximately 12% of this population report feeling trapped in their own homes. Loneliness increases the risk of a range of mental health conditions such as depression¹³. It is concerning that suicide rates are highest in those over the age of 70 worldwide¹⁴. This has lead Theresa May, the Prime Minster, in January 2018 to appoint Tracey Crouch as the first ever Loneliness Minister in the UK.

Holt-Lunstad suggests loneliness has the same impact as smoking 15 cigarettes a day and is worse than excessive alcohol, obesity and inactivity¹⁵. Several studies have reported increased nutritional risk in older people who eat alone, associated with their lack of enjoyment in meals¹⁶⁻²⁰. Widowhood in older people can be related to loss of interest in mealtimes, poor diet choices and a loss of interest in cooking²¹’²².

Locher et al found that rather than living arrangements, it was commensality that contributed positively to nutrition in older people²³. For instance, diet is improved if a Meals-on-Wheels delivery volunteer stays with the recipient during their mealtime²⁴. This was particularly pronounced if the meal was shared with family and friends²⁵. A study showed retired older women created a quasi-social environment using television, radio or even pets when eating alone²⁶.

A number of studies have also looked at the importance of mealtimes for older people in care homes. Gubrium²⁷ noted mealtimes are central to residents’ daily lives and it has been described as the highlight of the day²⁸. Mealtimes have the benefit of providing a structured routine and help to promote normality²⁹.

Mealtimes in care homes are social occasions that encourage companionship and provide opportunities for conversations³⁰. Studies have observed reciprocity and support between residents during mealtimes, where they help each other by passing dishes to their neighbours, serving each other and ensuring everyone had what they needed³¹⁻³³. Efforts were made to include those with hearing impairment in conversations³².

Residents in care homes are also known to reminisce back to their past and discuss their own cooking experiences over meals, which led to a kinship between residents and with staff³²’³³. Many studies have shown friendship is an important factor in the well-being of older people³⁴’³⁵. Philpin et al observed a cheerful environment when residents celebrated traditional ceremonies together over food, especially when encouraged to participate in the preparation of food. These rituals were helpful in maintaining their identity and connecting them to their memories of home and family³². Studies have shown that couples with dementia use meal preparation as a way to reinforce their own relationship³⁶.

For older people, mealtimes can help shape their relationships³⁷ by developing a shared sense of belonging attitudes, culture and goals. When older people are encouraged to undertake regular family meals it leads to an increase in nutrient intake, weight gain and quality of life²⁵’³⁸. These effects are thought to be facilitated indirectly by commensality, by improving mood and self-esteem³⁹’⁴⁰. The resulting psychological well-being reduces rates of mortality, slows functional decline and decreases the risk of cognitive impairment⁴¹⁻⁴⁴.

It is important to consider these reciprocal benefits of commensality and social support, and to identify ways to utilise them in combating loneliness and isolation in older people. One of the first steps could be simply raising awareness by discussing these topics with older people and their families when opportunity arises. Older people charities could organise fund-raising events where families are encouraged to cook traditional family recipes together and share them with the local community in the form of a food festival or a communal feast. Or a local food event akin to ‘Come Dine with Me’ could be set up in the community, where older people and their families take it in turns to cook for each other.

These approaches could instil the development of a coordinated activity, involving shopping, cooking and conversation between different generations over meals, hopefully enforcing a sense of belonging within the community and improving the mental and physical well-being of older people.


1. Fischler, C. 1988. Food, self and identity. Soc Sci Inf. 27, 2, 275–92.

2. Shatenstein, B. & Ghadirian, P. 1998. Influences on diet, health behaviours and their outcomein select ethnocultural and religious groups. Nutrition. 14, 2, 223–30.

3. Evans, B.C., Crogan, N.L. & Schultz, J.A. 2005. The meaning of mealtimes: connection to the social world of the nursing home. Journal of Gerontological Nursing. 31, 2, 11-17.

4. Ochs, E. & Shohet, M. 2006. The cultural structuring of mealtime socialisation. New Directions for Child and Adolescent Development.111, 35-49.

5. Street, D. Burge, S. Quadagno, J. & Barrett. 2007. The salience of social relationships for resident well-being in assisted living. Journal of Gerontology. 62B, 2, 129-134

6. de Castro, J.M. Brewer, E.M. Elmore, D.K. & Orazco, S. 1990. Social facilitation of the spontaneous meal size of human occurs regardless of times, place, alcohol or snacks. Appetite. 15, 89-101.

7. Durkheim E. 1951. Suicide: A Study in Sociology. Spaulding JA, Simpson G, trans. Glencoe, IL: Free Press.

8. Hetherington, M.M. Anderson, A.S. Norton, G.N. & Newson, L. 2006. Situational effects on meal intake: A comparison of eating alone and eating with others. Physiol Behav. 30, 88, 4-5, 498-505.

9. Sahyoun, N.R. Zhang, X.L. 2005. Dietary quality and social contact among a nationally representative sample of the older adult population in the United States. J Nutr Health Aging. 9, 3, 177–83.

10. Mennell, S. Murcott, A. & van Otterloo, A.H. 1992. The Sociology of Food: Eating, Diet and Culture. Newbury Park (CA): Sage.

11. Mestdag, I. & Glorieux, I. 2009. Change and stability in commensality patterns: a comparative analysis of Belgian time-use data from 1966, 1999 and 2004. Sociol Rev. 57, 703–726.

12. Organisation for Economic Co-operation and Development (FR). 2013. Trends in Shaping Education 2013.Paris: OECD publishing; Figure 2.3. Home alone: the rise in single-person households. 40.

13. Aziz, V. 2017. Health, Social Care and Sports Committee Inquiry into Loneliness and Isolation. Royal College of Psychiatrists, Consultation Response.

14. WHO. 2014. Preventing Suicide: A Global Imperative.

15. Holt-Lunstad, J. Smith, T.B. & Layton, J.B. 2010. Social relationships and mortality risk: a meta-analytic review. PLoS Medicine. 7,7.

16. Shahar, D. Shai, I. Vardi, H. & Fraser, D. 2003. Dietary intake and eating patterns of elderly people in Israel: Who is at nutritional risk? Eur J Clin Nutr. 57, 1, 18–25.

17. Lennie, T.A. Moser, D.K. Heo, S. Chung, M.L. & Zambroski, C.H. 2006. Factors influencing food intake in patients with heart failure: a comparison with healthy elders. J Cardiovasc Nurs. 21, 2,123–9.

18. Wikby, K. & Fagerskiold, A. 2004. The willingness to eat: an investigation of appetite among elderly people. Scand J Caring Sci. 18, 2, 120–7.

19. Callen, B.L. Wells, T.J. 2003. Views of community-dwelling, old-old people on barriers and aids to nutritional health. J Nurs Scholarsh. 35, 3, 257–63.

20. Moss, S.Z. Moss, M.S. Kilbride, J.E. & Rubinstein, R.L. 2007. Frail men’s perspectives on food and eating. J Aging Stud. 21, 4, 314–24.

21. Rosenbloom, C.A. & Whittington, F.J. 1993. The effects of bereavement on eating behaviours and nutrient intakes in elderly widowed persons. J Gerontol. 48, 4, 223–9.

22. Shahar, D.R. Schultz, R. Shahar, A. & Wing, R.R. 2001. The effect of widowhood on weight change, dietary intake, and eating behavior in the elderly population. J Aging Health.13, 2,186–99.

23. Locher, J.L. Robinson, C.O. Roth, D.L. Ritchie, C.S. & Burgio, K.L. 2005.The effect of the presence of others on caloric intake in homebound older adults. J Gerontol A Biol Sci Med Sci. 60A,11, 475–8.

24. Suda, Y. Marske, C.E. Flaherty, J.H. Zdrodowski, K. & Morley, J.E. 2001. Examining the effect of intervention to nutritional problems of the elderly living in an inner city area: a pilot project. J Nutr Health Aging. 5, 2,118–23

25. de Castro, J.M. 1994. Family and friends produce greater social facilitation of food intake than other companions. Physiol Behav. 56, 3, 445–55.

26. Sidenvall, B. Nydahl, M. & Fjellstrom, C. 2000. The meal as gift – the meaning of cooking among retired women. J Appl Gerontol. 19, 4, 405-23.

27. Gubrium, J. F. 2012. Living and Dying at Murray Manor. University Press of Virginia, Charlottesville, Virginia.

28. Commission for Social Care Inspection (CSCI). 2006. Highlight of the Day?: Improving Meals for Older People in Care Homes. Commission for Social Care Inspection, London.

29. Pearson, A. et al. Mealtime in nursing homes: the role of the nursing staff. Journal of Gerontological Nursing, 29 6 40-7.

30. Savishinsky, J. S. 2003. ‘Bread and butter’ issues: food, conflict, and control in a nursing home. In Stafford, P. B. (ed.), Gray Areas: Ethnographic Encounters with Nursing Home Culture. School of American Research Press, Santa Fe, New Mexico. 23-120.

31. Godfrey, M. Townsend, J. & Denby, T. 2004. Building a Good Life for Older People in Local Communities: The Experience of Ageing in Time and Place. Joseph Rowntree Foundation, York, UK.

32. Philpin, S. Merrell, J. Warring, J. Hobby, D. & Gregory, V. 2014. Memories, identity and homeliness: the social construction of mealtimes in residential care homes in South Wales. Ageing & Society. 34. 753-89.

33. Charras, K. & Frémontier, M. 2010. Sharing Meals With Institutionalized People With Dementia: A Natural Experiment. Journal of Gerontological Social Work. 53, 5, 436-448

34. Aday, R. H. Kehoe, G. C. & Farney, H. 2006. Impact of senior center friendships on aging women who live alone. Journal of Women and Aging, 18, 53–73.

35. Payne, L. L, Mowen, A. L. & Montoro-Rodriguez, J. 2006. The role of leisure style in maintaining the health of older adults with arthritis. Journal of Leisure Research, 38, 20–45.

36. Hellström, I. Nolan, M. & Lundh, U. 2005. ‘We do things together’: A case study of ‘couplehood’ in dementia. Dementia, 4,1, 7–21.

37. Wiles, J. 2005. Conceptualizing place in the care of older people: the contributions of social gerontology. International Journal of Older People Nursing, 14, 8b, 100-8.

38. Nijs K. de Graaf, C. Siebelink, E. Blauw, Y.H. Vanneste, V. Kok, F. J. & van Staveren, W. A. 2006. Effect of Family-Style Meals on Energy Intake and Risk of Malnutrition in Dutch Nursing Home Residents: A Randomized Controlled Trial .J Gerontol A Biol Sci Med Sci. 61, 9, 935–942

39. Wikby, K. Fagerskiold, A. 2004. The willingness to eat: an investigation of appetite among elderly people. Scand J Caring Sci. 18, 2,120–7.

40. Pierce, M. 2002. Nutrition Support to Elderly Women: Influence on Diet Quality. New York: Garland.

41. Park, N.S. 2009. The relationship of social engagement to psychological well-being of older adults in assisted living facilities. Journal of Appl Gerontol. 28, 4, 461-81.

42. Mendes de Leon, C. F. Glass, T. A. & Berkman, L. F. 2003. Social engagement and disability in a community population of older adults. American Journal of Epidemiology, 157, 7, 633-642

43. Rozzini, R. Bianchetti, A. Franzoni, S. Zanetti, O. & Trabucchi, M. 1991. Social functional and health status influences on mortality: Consideration of a multidimensional inquiry in a large elderly population. Journal of Cross-Cultural Gerontology, 6, 83-90.

44. Bassuk, S. S. Glass, T. A. & Berkman, L. F. 1999. Social disengagement and incident cognitive decline in community-dwelling elderly persons. Annals of Internal Medicine, 3, 165-173.
... More

Conflict of interest: None declared

Write a reply

Smokefree acute adult mental health inpatient wards: the service user experience

Elena Ratschen, Senior Lecturer in Health Services Research, The University of York, Department of Health Sciences, UK
Pete Stewart, Mental Health Nurse, Sheffield Health and Social Care NHS Foundation Trust, Sheffield, UK
Michelle Horspool, Senior Research Manager, Sheffield Health and Social Care NHS Foundation Trust, Sheffield, UK
Moira Leahy, Consultant Clinical Psychologist, Sheffield Health and Social Care NHS Foundation Trust, Sheffield, UK
26 April 2018

Tobacco smoking among people with severe mental illness (SMI) can reach prevalence rates up to 70%¹ compared to ~16% in the UK general population² and has been recognised as the largest contributor to health inequalities in this population, causing on average 17 years loss of life.³ Historically deeply embedded in the culture of mental health treatment environments,¹ smoking until very recently remained the norm in inpatient settings. However, mental health Trusts across England are currently implementing national guidance by the National Institute for Health and are Excellence (NICE)⁴ to become completely smokefree, in line with the recent Tobacco Control Plan for England.⁵ Due to the strong and complex links between tobacco smoking and mental illness¹’⁶ and the historic ‘smoking culture’ in mental health,⁷’⁸ implementing completely smokefree mental health inpatient settings is not straightforward, and challenges are recognised.⁴ To date, little is known about the impact of smokefree policy implementation on patients’ smoking behaviour and the inpatient experience.

We conducted structured interviews with inpatients on four acute adult mental health inpatient wards of a Northern mental health Trust between October and December 2016, following complete smokefree policy implementation in May 2016. Patients well enough to engage were invited to take part by ward staff, independent of their smoking status. Interviews were conducted by a team of mental health professionals using a questionnaire covering the following themes: 1) tobacco and electronic cigarette use before admission; 2) experience of being on a smokefree ward (communication of smokefree policy, current tobacco and electronic cigarette use, use of nicotine replacement therapy, motivation to stop (MTSS)⁹, strength of urges to smoke (SUTS)¹⁰, support and activities used to manage smokefree stay, thoughts on ‘the best’ and ‘the hardest’ thing about the smokefree policy, and on potential to improve patient support; and 3) thoughts about smoking and support needs after discharge. Quantitative data were summarised using descriptive statistics; qualitative content analysis¹¹ was performed to thematically summarise responses to open questions. The project was undertaken as a Service Improvement Project and registered with the Trust Audit and Clinical Governance Department.

Of the 35 individuals interviewed, 74% (26) reported they had been smokers before admission to hospital. Half (50%; 13) indicated they had been offered Nicotine Replacement Therapy (NRT) within 30 minutes of admission, and 65% (17) had been using NRT products since their admission to manage nicotine withdrawal. Almost two thirds (62%; 16) reported the use of personally purchased electronic cigarettes after admission; 20% (7) stated they had used electronic cigarettes before admission. Asked to indicate how their smoking behaviour had changed since admission, 15% (4) of participants reported they had quit, 70% (18) they were smoking less than usual, and 12% (3) they were smoking as much as before (one participant did not answer the question). No participants had started smoking since admission. In terms of intentions to quit smoking, 20% (4) stated they ‘really wanted to stop but did not know when’, 12% (3) they ‘wanted to stop and hoped to soon’, 8% (2) they ‘really wanted to stop and intended to in the next 3 months’, and 8% (2) that they ‘had stopped whilst on the ward and did not intend to start smoking again’.

Asked ‘how much of the time have you felt the urge to smoke in the past 24 hours?’, 27% (7) of smokers stated ‘a lot of the time’, 15% (4) ‘almost all of the time’, and 23% (6) ‘all of the time’. Almost one third (31%; 8) indicated that urges to smoke were ‘very strong’, and 15% (4) said they were ‘extremely strong’, suggesting that patients were not accessing or using sufficient nicotine replacement therapy. When prompted to indicate, on an ascending scale from 1 to 10, how well they had felt supported sufficiently by staff to be smokefree during the day, the average score was 5.25.

Qualitative responses to the question concerning the ‘most challenging aspects of the policy’ were coded and categorised into the following themes: struggling with cravings; loss of a coping strategy to manage stress on the ward; perceived loss of freedom; boredom; feelings of guilt when smoking covertly; and seeing others smoke covertly or openly ignoring the policy. Several participants reported that seeing others smoke, in the context of a policy that was inconsistently adhered to, had undermined their initial efforts to remain abstinent.

Almost two thirds (60%; 21) of all participants reported positive effects of the policy, including ‘the feeling to be healthier’; a chance to give up smoking; the ‘discovery’ of electronic cigarettes; freedom from being bullied into giving away cigarettes to other patients; and a healthier, ‘fresher’ smokefree environment. Electronic cigarettes as potential aid to support abstinence, more activities to replace smoking, more one-to-one support from staff, pre-admission information and written information on NRT products were suggested by participants to improve patient support. Almost half (42%; 11) stated they would appreciate support to help maintain or make changes related to smoking after discharge.

Despite the obvious limitations of this small service improvement project, its findings are timely and important for the development of further research. In line with previous work¹², they suggest that the implementation of smokefree policies in mental health inpatient settings has the potential to support positive changes in patients’ smoking behaviours that may continue beyond discharge. Although not all service users abstain from or quit smoking following a hospital admission, our findings suggest that, unlike in previous times, people no longer appear to increase or start smoking during a mental health inpatient stay¹. Unquestionably, it is important to recognise and address the challenges that were reported by our participants. Much work is still to be done. However, it seems crucial, at this time of change, to focus also on the positives, as reported in this project. Smokefree policies, in combination with comprehensive evidence-based smoking treatment, have huge potential to promote behaviour change in people who smoke at time of admission to an acute mental health unit. We need to work together to realise this potential in full.


1. The Royal College of Physicians and the Royal College of Psychiatrists RCo. Smoking and Mental Health. A joint report. London, March 2013.

2. The National Office for Statistics. Adult smoking habits in the UK: 2016.

3. Action on Smoking and Health (ASH). The Stolen Years. The Mental Health and Smoking Action Report. London, 2016.

4. National Institute for Health and Care Excellence (NICE). Smoking Cessation in secondary care: acute, maternity and mental health services. PH48. 2013. National Institute for Health and Clinicel Excellence; 2013.

5. Department of Health. Towards a smokefree generation: tobacco control plan for England. London2017.

6. Olivier D, Lubman DI, Fraser R. Tobacco smoking within psychiatric inpatient settings: biopsychosocial perspective. The Australian and New Zealand journal of psychiatry. Jul 2007;41(7):572-580.

7. Lawn SJ. Systemic barriers to quitting smoking among institutionalised public mental health service populations: a comparison of two Australian sites. The International journal of social psychiatry. Sep 2004;50(3):204-215.

8. Ratschen E, Britton J, McNeill A. The smoking culture in psychiatry: time for change. The British journal of psychiatry : the journal of mental science. Jan 2011;198(1):6-7.

9. Kotz D, Brown J, West R. Predictive validity of the Motivation To Stop Scale (MTSS): a single-item measure of motivation to stop smoking. Drug and alcohol dependence. Feb 01 2013;128(1-2):15-19.

10. Fidler JA, Shahab L, West R. Strength of urges to smoke as a measure of severity of cigarette dependence: comparison with the Fagerstrom Test for Nicotine Dependence and its components. Addiction. Mar 2011;106(3):631-638.

11. Graneheim H, Lundmann B. Qualitative content analysis in nursing research: concepts, procedures and measures to achieve trustworthiness. Nurse Education Today. Feb 2004; 24 (105-112).

12. Stockings EA, Bowman JA, Prochaska JJ, et al. The impact of a smoke-free psychiatric hospitalization on patient smoking outcomes: a systematic review. The Australian and New Zealand journal of psychiatry. 2014;48(7):617-633.
... More

Conflict of interest: Finance The project was supported by the NIHR CLAHRC Yorkshire and Humber, and Sheffield Health and Social Care NHS Foundation Trust. The views expressed are those of the authors and not necessarily those of the NHS, the NIHR or the Department of Health.

Write a reply


Reply to: Submit a response

Your details

Conflicting interests

Do you have any conflicting interests? *